A Pilot Randomized Trial of an Interactive Web-based Tool to Support Surrogate Decision-makers in the ICU

Breakdowns in clinician-family communication in ICUs are common, yet there are no easily scaled interventions to prevent this problem. To assess the feasibility, usability, acceptability, and perceived effectiveness of a communication intervention that pairs proactive family meetings with an interactive, web-based tool to help surrogates prepare for clinician-family meetings. We conducted a two-arm, single blind, patient-level randomized trial comparing the Family Support Tool to enhanced usual care in 2 ICUs in a tertiary care hospital. Eligible participants included surrogates of incapacitated patients judged by their physicians to have ≥40% risk of death or severe long-term functional impairment. The intervention group received unlimited tool access, with prompts to complete specific content upon enrollment and before two scheduled family meetings. Before family meetings, research staff shared with clinicians a one-page summary of surrogates' main questions, prognostic expectations, beliefs about the patient's values, and attitudes about goals of care. The comparator group received usual care enhanced with scheduled family meetings. Feasibility outcomes included the proportion of participants who accessed the tool before the first family meeting, mean number of logins, and average tool engagement time. We assessed tool usability with the System Usability Scale (SUS), tool acceptability and perceived effectiveness with internally developed questionnaires, and quality of communication and shared decision-making using the Quality of Communication questionnaire. Of 182 screened patients, 77 were eligible. We enrolled 52 (67.5%) patients and their primary surrogate. 96% of intervention surrogates (24/25) accessed the tool before the first family meeting (mean engagement time 62 minutes ±27.7) and logged in on average 4.2 times (±2.1) throughout the hospitalization. Surrogates reported the tool was highly usable (mean 82.4/100), acceptable (mean 4.5/5±0.9), and effective (mean 4.4/5±0.2). Compared to the control group, surrogates who used the tool reported higher overall quality of communication (mean 8.9/10±1.6 versus 8.0/10±2.4) and higher quality in shared decision-making (mean 8.7/10±1.5 versus 8.0/10±2.4), but the difference did not reach statistical significance. It is feasible to deploy an interactive web-based tool to support communication and shared decision-making for surrogates in ICUs. Surrogates and clinicians rated the tool as highly usable, acc